Miscarriage Care and Facilities in Scotland: Scoping Report National Overview

Graded approach to miscarriage

The Lancet series on Miscarriage Matters provided information on the provision of treatment and care after first, second and third or subsequent miscarriage. The Lancet series proposed a graded approach to the treatment of recurrent miscarriage, where after one miscarriage women would have their health needs evaluated and would be provided with information and guidance to support future pregnancies. If a second miscarriage occurs, women should be offered an appointment at a miscarriage clinic for a full blood count and thyroid function tests and have extra support and early scans for reassurance in any subsequent pregnancies. After three miscarriages additional tests, including genetic testing and a pelvic ultrasound, should be offered.

The following sections of this report are based on the Lancet series. The sections are designed to ascertain the extent to which the graded approach is currently being delivered in Health Boards across Scotland.

In 13 Health Board areas a graded approach to the treatment of miscarriage is adopted or can be accessed. NHS Shetland reported that they do not provide a graded approach to recurrent miscarriage, however they are able to access this out with the Health Board area in NHS Grampian. See Table 17.

NHS Forth Valley do not provide a graded approach for recurrent miscarriage and reported that there are no plans to implement this. This was attributed to lack of staff training and cost/finance. While NHS Forth Valley stated a graded approach to recurrent miscarriage is not currently adopted, some of the elements of a graded approach are provided. Further details can also be found in the report NHS Forth Valley - Miscarriage care in Scotland - Scoping report.

17 of the 44 sites said a graded approach to the treatment of recurrent miscarriage is adopted and provided on their site. A further 9 sites reported that they are able to access a graded approach to the treatment of recurrent miscarriage by referring to another site in their Health Board area.

After first miscarriage

The Lancet series on Miscarriage Matters recommended the provision below (Table 18, Table 19) is available after a first miscarriage. Table 18 indicates the number of Boards that currently provide the elements of miscarriage care listed after a first miscarriage and Table 19 indicates the number of sites that currently provide them.

After a first miscarriage many of the services and provision outlined in The Lancet series are provided in all Health Board areas. Vaginal micronised progesterone in women with early pregnancy bleeding and a history of miscarriage is not offered in all 14 Health Boards with some sites referring to the NICE Guidelines that state this should be offered for women with early pregnancy bleeding and a history of miscarriage rather than a first miscarriage^[10]. Screening for mental health issues was provided in 12 of the 14 Health Boards. Some sites stated that there are no screening tools available for use and others stated that this is offered following a referral to another service (GP or Mental Health Teams). The development of an individualised care plan is provided in 13 of the 14 Health Boards with NHS Forth Valley not providing this service.

*Vaginal micronised progesterone is recommended for women with early pregnancy bleeding and a history of miscarriage.

* This question was not asked of sites with A&E facilities only, 39 sites were asked in total

**Vaginal micronised progesterone is recommended for women with early pregnancy bleeding and a history of miscarriage.

The Lancet series stated that adopting a graded approach would involve women being guided to information about miscarriage, resources to address their physical and mental health needs following pregnancy loss, and ways to optimise their health for future pregnancy after a first miscarriage.

After a first miscarriage the following services listed in Table 20 below were explicitly stated in the miscarriage matters series^[11]. Sites were asked if they routinely signpost patients to any of the following. While this signposting is provided in most Health Board areas, there is a lack of consistency among sites both within and between Health Board areas in terms of whether this is routine for all patients.

In the Health Boards where women are not signposted, general advice on maternal optimisation of pregnancy such as weight management, pregnancy vitamins, smoking cessation advice is provided and women are signposted to the Miscarriage Association.

* This question was not asked of sites with A&E facilities only, 39 sites were asked in total

After second miscarriage

Following a second miscarriage, the Lancet series stated that when the graded approach is followed women will be offered an appointment at a miscarriage clinic that could be nurse or midwifery-led, in which tests for full blood count and thyroid function are offered, in addition to discussing lifestyle issues. Referral for specialist care will be arranged if tests are abnormal or if there is chronic medical or mental health concerns. Women will have access to support and early pregnancy reassurance scans in subsequent pregnancies.

After a second miscarriage no Health Board delivers all of the elements of the service provision as outlined in the Lancet series. There was variability in approach within and between Health Board areas (Table 21).

Appointment at a nurse-led or midwife-led miscarriage clinic is not planned to be implemented in many Health Boards as clinics are consultant-led. Women would be seen at a miscarriage clinic but by a consultant rather than a nurse or midwife.

Continuity of care is not offered in all Health Board areas after a second miscarriage with two Health Boards stating this was due to staff recruitment and retention and in some cases lack of specialised nursing staff and staff training. Tests for full blood count and thyroid function and discussions about lifestyle issues in relation to future pregnancies are not routinely offered in all Health Boards or all sites that provide miscarriage care after a second miscarriage.

Access to support and early pregnancy reassurance scans in subsequent pregnancies is available in 12 of the 14 Health Boards but not in all sites included in the survey. Where support and early pregnancy reassurance scans are not offered, sites stated a lack of space, staff recruitment, staff training, finance/cost, lack of equipment and lack of scanning resource as barriers to providing reassurance scans after a second miscarriage.

The Lancet series concludes that there is high-quality evidence showing vaginal micronised progesterone increases livebirth rates, for women who have early pregnancy bleeding and a history of miscarriages. After a second miscarriage vaginal micronised progesterone is offered in 12 of the 14 Health Boards although not all sites that care for women experiencing a miscarriage provide this service. NHS Lothian does not provide vaginal micronised progesterone after a second loss but can provide this after a third miscarriage. NHS Orkney does not provide vaginal micronised progesterone (Table 22).

* This question was not asked of sites with A&E facilities only, 39 sites in total were asked

After third and subsequent miscarriage

The Lancet series states in the graded model approach to miscarriage, after a third miscarriage, women will be offered an appointment at a medical consultant-led clinic, in which additional tests and a full range of treatments can be offered. Pregnancy tissue from the third and any subsequent miscarriages will be sent for genetic testing. Blood tests for antiphospholipid antibodies and a pelvic ultrasound scan (ideally three-dimensional transvaginal) will be arranged and, if necessary, parental karyotyping will be offered depending on the clinical history and the results of the genetic analysis of pregnancy tissue from previous losses. Appropriate screening and care for mental health issues and future obstetric risks, particularly preterm birth, fetal growth restriction, and stillbirth, will need to be incorporated into the care pathway for couples with a history of recurrent miscarriage^[12].

No Health Board is delivering all elements of the graded approach outlined in the Lancet series after a third or subsequent miscarriage. The service provision is variable, while almost all options are being delivered in all Health Boards this was site dependent and there was variability in approach both within and between Health Board areas (Table 23).

As stated above the Lancet series concludes that there is high-quality evidence showing vaginal micronised progesterone increases livebirth rates, for women who have early pregnancy bleeding and a history of miscarriages. After a third or subsequent miscarriage all Health Boards except NHS Orkney provide this.

The Lancet series stated that as psychological morbidity is common after pregnancy loss, effective screening instruments and treatment options for mental health consequences of miscarriage need to be available^[13]. Appropriate screening for mental health issues after a third or subsequent miscarriage is provided in 12 of the 14 Health Boards. It is unclear across all Health Boards if screening is routine for all women and whether a validated tool is being used. Two Health Boards stated that this is not provided. NHS Dumfries and Galloway stated that there is not a formal screening process, but women could be referred to mental health services if required. NHS Forth Valley stated screening for mental health issues is not available due to lack of staff training, however, women are directed to other services if felt they are at risk.

* This question was not asked of sites with A&E facilities only, 39 sites in total were asked